Provider Self-Audit Reporting Form

Please complete all sections of this form to report self initiated payback to Trillium Health Resources based on out of compliance issues found during a Voluntary Self Audit conducted at your provider agency.

Instructions on how to complete an adjustment/void can be found on Trillium’s website in the Provider Documents and Forms as the Trillium Replacement and Voided Claims Process.

Date of Submission

mm/dd/yyyy

Provider Name

Provider Address

Provider NPI Number

Provider Contact Name

Provider Contact Email

Related Case

Is the Self-Audit in relation to an open case with Trillium?

If yes above, Case Number?

Identified Problem

What were the issue(s) found during the Self-Audit?

Date of Services Included in Self-Audit

What was the date of service reviewed or date range of services reviewed during your Self-Audit?

What records were reviewed?

Description of what information was reviewed during the Self-Audit.

Findings

What was the outcome of the Self-Audit?

Actions Taken

Based on the outcome of the Self-Audit, what actions were taken to remedy the problems found including change in policies, procedures and/or process.

Void/Replacement Claim Type

How will your agency be replacing/voiding the claims paid in error?

Claim Count

Please identify the number of claims being replaced/voided.

Recoupment Amount Total

Please identify the amount of funds being returned to Trillium paid in error.

Self-Audit Document Submissions

The following items may be attached if applicable:

Completed Self- Audit Replacement/Void Claims Chart, if provider submits replacement/voided claims.
Any other document supporting the Self-Audit.

Drop your files here

Send me a copy of my responses

Report Abuse